Monday, December 21, 2009

Addiction, Part I

We are here going to discuss addiction and the various degrees and sub-categories thereof: dependence, habit, obsession-compulsion, drug abuse, enabler, conditioned reflex, and illegal drug use. We shall see that the categories are not clear-cut, boundaries of groups are not precise, and behavioral scientists disagree about definitions. This discussion will not include membership in religious sects and drug use in their rituals,since that will be discussed in a future blog.

Again, many of the above definitions are conditioned by our culture (see my previous blog on insanity). The old joke that an alcoholic is someone who drinks more than his doctor does is particularly relevant here. Many doctors forget that they define what is "normal" for their patients, and doctors, especially psychiatrists, have to be careful to maintain a "poker face". (It is trivial to add here that if you are demonstrating cardiac auscultation to a medical student on a female patient with a V/VI holosystolic murmur, you should refrain from using the phrase "a palpable thrill".)

First of all, the label of "enabler" should be stricken. The only way to influence the legal behavior of someone with whom you are involved is by request, by order, by saying "do it if you love me", or by threatening to leave if the behavior does not stop, i.e. basically by compulsion. I have found, for instance, in 25 years of practice that the only way to force a male alcoholic to stop is for his boss to threaten him with loss of his job, and, in the case of women, for the judge to threaten them with loss of their children. Only then is their ego threatened enough to change their behavior, and it still generally involves at least 30 days inpatient treatment. You are not responsible if your loved one continues self-destructive behavior, although their "right" to self-destruction does not mean that it is the "right" thing to do. Of course, if their behavior damages them permanently, you have the job of caring for them, which seems to be grossly unfair. As a simple example, if your spouse chews his/her fingernails, are you a fingernail-chewing enabler? I know that it is painful to watch such behavior, but as I often tell spouses, smokers know they shouldn't smoke, overweight people and diabetics know they should lose weight,etc.But once you tell them more than twice, you are nagging them, and my male patients tell me they react to such nagging with anger and passive-aggressive behavior. It is not enabling to stay with someone whose behavior you disagree with or you feel is self-destructive, any more than the person can be cured by your walking out. (When children are present, however, the answer may be different, and then case-by-case analysis and judgment is needed.)

Obsessive-compulsive behavior is best described as repetitive behavior that the patient wishes he/she could stop, or that interferes with the ability to work, love, or play (pace Freud). Again, I am deliberately omitting any discussion of religion, including the behavior of self-flagellation so brilliantly shown in "The Seventh Seal". This problem is very difficult to treat psychiatrically, since the behavior is a substitute to ward off anxiety, and the true cause cannot always be found. The unwanted behavior can range from going back home to make sure the oven is turned off, to washing your hands 20 times a day, to taking one hour to put on makeup, etc. Anorexia is probably the end-point of o-c worrying and behavior about one's weight and self-image. At what point does compulsive self-pleasuring become a true problem? (The latest data shows that 95% of college men self-pleasure , and the other 5% are liars.) If the o-c behavior is mild, the patient will probably not even admit it as such (how many baths a day is too many, when 100 years ago only upper-class Englishmen bathed as often as once a week?). If you are a compulsive gambler as Michael Jordan apparently may have been, but you can afford to lose $100,000/month, is it still a problem?

Habit is just mild o-c behavior that is socially acceptable, and later becomes reassuring to the user. It is not threatening or dangerous, and can even engender a sense of pleasure, similar to the baseball player who always makes sure to step on the foul line when leaving the playing field, and avoiding it upon entering. In fact, alteration of habits is often an early indication of mental change, whether the change is falling in love, or early Alzheimers.

Addiction is the most complex behavior of all, and the most difficult to define. Classically, addiction to a drug is defined as a combination of drug-seeking behavior, even if it is illegal, tolerance, and withdrawal effects upon abrupt cessation. (I once took care of a patient who was admitted at his request to help him break his addiction to a legal drug:he swallowed up to 40 nitro-glycerine tablets a day, because he enjoyed the sensation triggered by abrupt drops in blood pressure.)The worst withdrawal effects are seen with CNS depressants, such as alcohol, tranquilizers, and other "downers", since the brain generates counter-chemicals which stimulate the brain, and the abrupt cessation of the drug lets the self-generated stimulating chemicals run riot, and hence the shakes, sweats, DT's, and the like which can kill the patient. Some doctors would say that a truly addicting drug is one that kills you if you stop it abruptly, or one that makes you feel compelled to increase the dosage, because of tolerance, until it kills or seriously damages your body, such as methamphetamine or other "upper" use. People also talk about "sex addiction", "gambling addiction", caffeine addiction, etc. None of these is acutely dangerous to the body (and, in fact, several studies have shown that caffeine is protective against adult-onset diabetes, especially in females). IMHO, all that is happening is that the immediate gratification and pleasure from the act far outweighs any thought of future problem. All babies demand instant gratification, and part of growing up is learning to defer this desire. However, it is extremely difficult to "prove" that hedonism is not a viable philosophy. The question of "rational" or Appolonian behavior vs. pleasure-seeking or Dionysian behavior is a motif that repeatedly recurs in human history. Euripides demonstrated the two sides in his play "The Bacchae", the 17th century English had the Cavaliers vs. the Roundheads, we had the Drys vs. the Wets,and today it is said that sex is a natural human occurrence in Europe, and an obsession in America. In South America, where the children are too poor to buy cocaine, they stuff rags in the gas tanks of autos and sniff the fumes to get high and escape their lives temporarily. It is very odd that smoking cigarettes creates a pleasant feeling, since the first few cigarettes make you cough horribly, so the pleasure is partly learned, as it is with marijuana. I also have trouble labeling it a true addiction (I know that most people disagree with me here) since anyone who takes a 12 hour plane ride stops smoking for at least that long, without any acute withdrawal symptoms. Most smokers "know" that cigarette smoking is health-threatening, but they feel that the particular cigarette they are about to smoke at this moment will not be especially damaging. Nicotine is an amazing drug about which we know very little: how does it both quench hunger and help one feel more comfortable after a full meal? Why does it have a calming effect? Why have various European studies shown that smokers apparently have a lower incidence of Parkinson's Disease? I tell my smokers that while they may not all get cancer, I can guarantee with 100% certainty the development of COPD/emphysema, and eventual dependence on an oxygen tank. In fact, sophisticated pulmonary function studies (not generally available outside of research labs) will show premature small airways closure in almost all smokers. Because of this, I prescribe Spiriva (ipatronium) inhalers for all my smoking patients. This drug has been demonstrated to slow the natural progression of symptomatic emphysema in non-smokers, and I can only hope that it will do the same for smokers.

At this point, I would like to show how some of the observed facts quoted above should suggest hypotheses which, in turn, require well-designed experiments to verify or disprove: 1) Why does coffee (? caffeine) drinking prevent or delay the onset of adult diabetes? Does it have to do with the effect of caffeine on the beta cells of the pancreas? We know that epinephrine (aka adrenaline in England) has an effect on these cells. Is there a local effect on potassium flux across the membranes of these cells? A proper experiment should tell us more about the nature of diabetes. 2) If cigarette smokers have a lower incidence of Parkinson's Disease, does this mean that stimulation of the nicotinic receptors in the human brain affects the dopaminergic neurons? Would a nicotine patch or daily use of nicotine gum have the same effect? We do know that smoking cigarettes seems to have a calming effect on some schizophrenics, so there is some nicotine---neural pathway or interaction occurring; we just don't know what it is, or if it can be stimulated without cigarettes. 3) It was simple observations that led the great scientists to marvelous concepts. Aristotle claimed that heavy bodies fell faster than lighter bodies, and Galileo asked himself (? the first gedanken experiment) what would happen if a heavy body were tied by string to a lighter body, and the two were dropped together. Einstein asked himself what the universe would look like if he rode on a beam of light at the speed of light, and developed the Theory of Special Relativity. He later used the Galilean result that all bodies fell at the same rate, and therefore had the same acceleration in a gravitational field. Since Force= (mass)x(acceleration)= (mass)x (gravity), this meant that inertial mass was equal to or equivalent to gravitational mass, and from this he developed the Theory of General Relativity.

I just realized that this blog is running longer than most of them, because this is a complex field, with much qualitative and little quantitative data. I will continue the discussion in a future blog. Just bear in mind that your brain tries to operate on the "seek pleasure, avoid pain" principle, and that it takes a lot of social training to prevent people from continual self-gratification, (see Freud's "Civilization and its Discontents"). When you were a baby you felt uncomfortable, cried, and your mother soothed you, usually with food or by holding you. Just like Pavlov's dog, we became conditioned to instant soothing, and it took a lot of training by our parents and schools to modify this. I'll leave you with the following experimental result: a biologist took lab rats, inserted an electrode into the pleasure center of their brains, connected the electrode to a battery, and connected the battery wiring to a bar in their cages. Every time a lab rat pushed the bar, the rat received an instant jolt of "pleasure". Every rat, without exception, pushed the bar repetitively and non-stop until death occurred from dehydration and starvation.This occurred even though rats, unlike humans, have no knowledge of death, and therefore no fear of it or need to blot such thoughts out by getting high.

1 comment:

A propos of the question of smoking as an addiction vs. a habit, one of my readers kindly reminded me that Orthodox Jews give up all smoking for 24 hours once a week, on the Sabbath, without apparent ill effects from withdrawal. I imagine the same holds true for Moslems during the daylight hours of Ramadan, as well as for any Catholics who give up smoking for Lent. They all can quit abruptly, without tapering or side effects, which is almost impossible to do with almost all drugs that occupy receptors in the brain (alcohol, ohenobarbital, valium, etc.).